What is a Medicare Advantage Plan?

It really hit home how frustrating Medicare is to seniors when a gentleman approaching 65 told me that learning Russian was much easier than understanding Medicare Plans. My experience has been that this is particularly true in understanding one’s choices with regard to Medicare Advantage Plans and how they compare to Medicare Supplements.

In the Research Triangle Area we are blessed with many excellent Medicare Advantage plans. With their zero or low premiums, it would be tempting to choose one without even considering the more expensive Medicare Supplements. However, they are not the best choice for all Medicare beneficiaries and there are a number of factors that must be considered before deciding if one of these plans is your best option.

Medicare Advantage Plans are also know as Medicare Health Plans or Part C.  They are managed by Medicare-approved private insurance companies and cover all benefits and services under Part A (which helps cover care in a hospital, skilled nursing facility, hospice or at home) and Part B (which helps cover services from doctors and other hospital providers, outpatient and home health care, some preventative services and durable medical equipment).  Although you can purchase a Medicare Advantage Plan without drug coverage, most have drug coverage (Part D). They often have extra benefits such as vision and dental discounts or gym memberships.

What types of Medicare Advantage Plans are available?

Health Maintenance Organization (HMO) Plans: You are required to go to doctors, other healthcare providers and hospitals in the plan’s network except in an emergency.

Preferred Provider Organization (PPO) Plans: Although you can go outside of the network of doctors, other healthcare providers and hospitals, you usually pay more.

Private Fee-For-Service (PFFS) Plans: You are allowed to go to any provider who will accept the plan’s terms and is willing to treat you. However, except for emergencies providers can refuse to accept you as a patient.

Health Maintenance Organization Point-Of- Service (HMO-POS) Plans: These are HMO plans that allow you to go outside the network for some services at a higher copayment or coinsurance.


How does a Medicare Advantage Plan compare with a Medicare Supplement?

Here are five ways these plans differ:

  1. As the name implies, a Medicare Supplement “supplements” what Original Medicare does not cover. How much is “supplemented” depends on the plan you choose. Plans range from a Plan F which covers 100% of the gaps that Medicare does not cover to a High Deductible F which has a $2200 annual deductible. Plan G is very popular since it is less expensive than an F and has the same coverage except the $183 Part B deductible. If you want coverage like Plan G or F, then a Medicare Advantage would probably not fit your requirements. With Medicare Advantage Plans there are co-pays for most services and a serious illness can result in several thousands of dollars of out-of-pocket medical expenses.
  2.  From a monthly premium standpoint, Medicare Advantage Plans are generally much less expensive. Many have very low or zero premiums.  However, like a Medicare Supplement you must have Part B and continue to pay your Part B premiums.
  3. Unlike Medicare Supplements that are sold today, most Medicare Advantage Plans do have drug coverage.
  4. With most Medicare Supplements you can move to another state or county without changing to another Supplement. With a Medicare Advantage Plan you must find a new plan when you move to another state and sometimes even when you move to a different county.
  5. Medicare Supplements usually allow the policy holder to go to any doctor, healthcare provider or hospital that accepts Medicare patients.  With a Medicare Advantage (except for an emergency) one must adhere to network restrictions to prevent paying an additional amount or not being covered by the plan.


What questions should you ask before you purchase a Medicare Advantage Plan?

1. Are my doctors in the plan’s network?   It is important that the doctors you see frequently, such your primary care physician, are in the plan’s network. Although a PPO Medicare Advantage Plan will allow you to go outside the network, you are likely to pay a higher amount.

2. Are the hospitals in my area in the plan’s network?   Except in the case of an emergency, not all hospitals take all Medicare Advantage Plans.

3. Are my prescription drugs in the plan’s formulary (list of drugs that a drug plan covers) and what is the co-pay for each drug?  Although most Medicare Advantage Plans include a prescription drug plan, their formularies are different. One or two expensive drugs that are not in a plan’s formulary can result in a huge out-of-pocket expenditure.

4. What are the co-pays, costs or co-insurance for hospital stays, physician office visits, diagnostic tests, outpatient surgery, ambulance services and emergency room visits?

5. What is the maximum total out-of-pocket per year? Typically this should include the amount you spend on co-pays for doctor visits and hospital stays as well as the cost of ambulance services or emergency room visits, but would not include your prescription drug cost or co-pays.

6. What are the monthly premiums?

7.  Does this plan offer extra benefits or services for eye exams, dental benefits, hearing aids, emergency care outside of the United States and free gym membership?

8. What is the “star rating” for this plan?  The federal government rates Medicare Advantage plans on a scale from one to five stars based on the quality and accessibility of care, consumer satisfaction surveys and other measures. Plans with three or more stars are given bonus government funding.

 Where can North Carolina residents get help choosing a Medicare Advantage Plan?

Government resources include the web site www.medicare.gov, a guide published by the Centers for Medicare & Medicaid Services named Medicare & You and the North Carolina Department of Insurance’s “Seniors’ Health Insurance Program” (SHIIP), which can be contacted via the web at www.ncshiip.com or  phone at 1-855-408-1212.

You can also contact an agent with a license to sell Medicare plans in North Carolina.  Agents who represent multiple insurance companies (known as brokers) can help you sort through your myriad of choices.  Since these agents are compensated by the companies they represent, you pay nothing for their expertise.